The Complexity, Relative Value, and Financial Worth of Curbside Consultations in an Academic Infectious Diseases Unit

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1 MAJOR ARTICLE The Complexity, Relative Value, and Financial Worth of Curbside Consultations in an Academic Infectious Diseases Unit Christopher Grace, 1,2 W. Kemper Alston, 1,2 Mary Ramundo, 1,2 Louis Polish, 1,2 Beth Kirkpatrick, 1,2 and Christopher Huston 1,2 1 University of Vermont College of Medicine and 2 Fletcher Allen Health Care, Burlington, Vermont Background. Curbside consultations are common in clinical practice. The complexity, relative value, and revenue loss associated with curbside consultations are not well defined. Methods. Curbside consultations performed during a 1-year period were studied. Each curbside consultation was assigned a Current Procedural Terminology (CPT) code on the basis of the inpatient versus outpatient status of the patient, initial versus subsequent care, and clinical complexity. On the basis of the CPT code, the physician work component of the relative value unit (wrvu) was assigned for each curbside consultation. The 2005 Centers for Medicaid and Medicare Services conversion factor of $37.89 per wrvu was used for cost estimates. Comparisons were made with formal consultations performed during the same time period. Results. A total of 1001 curbside consultations were fielded: 66% involved outpatients, and 97% were coded as initial consultations. A total of 78% of curbside consultations were considered complex in nature, being assigned a CPT code of level 4 5, including 84% of the inpatient and 75% of the outpatient curbside consultations. These curbside consultations would have generated 2480 wrvus. During the same period, formal consultations generated 12,121 wrvus. Thus, curbside consultations represented 17% (2480/14,601) of the clinical work value of the infectious diseases unit. If the infectious diseases unit had performed these curbside consultations as formal consultations, an additional $93,979 in revenue would have been generated. Conclusions. Curbside consultations are common and complex. The curbside consultation should be incorporated into measures of infectious diseases providers productivity and compensation. Curbside consultations, also referred to as informal, telephone, or sidewalk consultations, have been a timehonored means of obtaining advice from physician colleagues [1 3]. They are commonly requested of infectious diseases specialists both in private and academic practice [4 7]. Although textbooks and literature searches are available to the provider to answer questions, providers are more likely to use informal consultations with a specialist to answer their questions [8 10]. For the health care provider requesting the advice, curbside consultations can save time [10], can be ed- Received 14 January 2010; accepted 6 June 2010; electronically published 4 August Reprints or correspondence: Dr. Christopher Grace, Infectious Diseases Unit, Fletcher Allen Health Care, Smith 275, 111 Colchester Ave., Burlington, VT (christopher.grace@vtmednet.org). Clinical Infectious Diseases 2010; 51(6): by the Infectious Diseases Society of America. All rights reserved /2010/ $15.00 DOI: / ucational [1], can reduce fear of litigation, and are free [11]. They may reduce hospital admissions, transfers, and emergency department visits and improve quality of care [12]. This may be especially important in rural areas with limited specialists [1, 12]. For the specialist, however, curbside consultations can be inconvenient and time consuming and may decrease the number of formal consultations [11 13]. Curbside consultations are neither reimbursed nor recognized as part of the work effort of the specialist. Today s medical economic climate has placed all physicians under closer financial scrutiny. Provider productivity is often benchmarked against national standards. Health care costs may be controlled by restricting access to subspecialty care by health care organizations [14 16]. These pressures may force primary providers to rely to an even greater extent on the informal consultation [17]. Despite the dichotomy of productivity benchmarks squeezing from one side and collegial expectations of Value and Worth of Curbside Consultation CID 2010:51 (15 September) 651

2 responding to numerous curbside consultations on the other, little is known about the complexity, relative value, or economic impact of this free advice. The purpose of this study was to measure both the complexity and the relative value of the curbside consultation, as well as to estimate the potential financial worth of the curbside consultation. METHODS This was a 1-year prospective study conducted from 1 July 2004 through 30 June 2005 at Fletcher Allen Health Care (FAHC), the teaching hospital of the University of Vermont College of Medicine. The study was approved by the University of Vermont Institutional Review Board. FAHC is a 500-bed community and tertiary care center in northwest Vermont, serving northern, western, and central Vermont and northeastern New York State. There are a limited number of infectious diseases specialists in this catchment area. Definitions and data collection. Curbside consultations were defined as any advice, suggestion, or opinion provided to any health care worker (HCW) concerning infectious diseases for which a formal consultation was not performed by the FAHC infectious diseases service. A formal consultation was defined as a patient visit that included history and physical examination, medical decision making, and documentation by written note. Curbside consultations could be performed in person, by telephone, or via letter or . Exclusions included questions regarding patients that were or had been formally consulted on by the infectious diseases service, questions pertaining to hospital infection control or employee health at FAHC, and questions related to use of restricted antibiotics at FAHC. If the requesting HCW had questions on several patients at the time of the request, each question was counted as a separate curbside consultation. If the HCW requested an additional curbside consultation about a patient for whom the HCW had previously received a curbside consultation from us, then followup CPT codes were used. If the requested curbside consultation concerned an inpatient at FAHC and a formal consultation was done on the same day, the curbside consultation was not counted. The HCWs requesting the curbside consultations were not informed about the study. During the study period, formal inpatient and outpatient consultations were tracked. Comparisons were made between formal and curbside consultations with regard to complexity and financial value. Complexity, relative value, and financial estimates. Each curbside consultation was given a Current Procedural Terminology (CPT) code. This assignment was based on the amount of history, physical examination, and laboratory data that had to be reviewed with the requesting provider, the severity of the patient illness, and the complexity of the medical decision making involved in answering the question. The CPT assignment relied on the experience of the infectious diseases specialists who had performed numerous similar formal consultations. The CPT codes used included inpatient initial consultation codes ( ), outpatient initial consultation codes ( ), inpatient subsequent care (follow-up) codes ( ), and outpatient subsequent care (follow-up) codes ( ). Curbside consultations were considered to be complex if they were assigned a CPT code of level 4 or 5 for initial inpatient, initial outpatient, or follow-up outpatient consultations or a CPT code of level 2 or 3 for inpatient follow-up consultations. On the basis of the CPT code assigned to the curbside consultation, a relative value unit (RVU) was assigned to each curbside consultation. Only the work RVU (wrvu) portion of the total RVU (comprising work, malpractice, and practice) was used. The wrvu values for 2004 were obtained from the Centers for Medicare and Medicaid Services (CMS). The wrvus used in these calculations were adjusted by the CMS Geographic Adjustment Factor for this region. The financial worth of the curbside consultations was estimated using the 2005 CMS conversion factor of $37.89 per wrvu. All wrvus and cost estimates have been rounded. Statistical analysis. The proportion of consultations categorized as complex versus not complex was compared between the curbside consultations and formal consultations by the x 2 test. RESULTS During this 1-year period, there were 1001 curbside consultations, with a mean standard deviation of curbside consultations per month. Of the 1001 curbside consultations, 342 (34%) concerned inpatients, and 659 (66%) concerned outpatients. Table 1 summarizes the number, wrvu value, and financial estimates of the 1001 curbside consultations. Of the inpatient curbside consultations, 96% (330/342) were initial consultations (CPT codes 99252, 99253, 99254, and 99255). Of the outpatient curbside consultations, 97% (640/659) were initial consultations (CPT codes 99242, 99243, 99244, and 99245). Of the 1001 curbside consultations, 782 (78%) were thought to be complex in nature. These included 499 (75%) of the 665 outpatient consultations and 283 (84%) of the 336 inpatient consultations. During that same year, there were a total of 6982 initial and follow-up formal consultations that generated 12,121 wrvus. According to the 2005 CMS conversion factor, the comparative financial worth of the formal consultations was $459,265. Of these formal consultations, 69% (4802/6982) were inpatient, of which 80% (3865/4802) were follow-up consultations. The 652 CID 2010:51 (15 September) Grace et al

3 Table 1. The Number, Relative Value, and Financial Value of Curbside Consultations by Inpatient or Outpatient Status for Initial and Follow-up Consultations Consultation type, measure Inpatient Outpatient Total Initial Number wrvu Financial value $33,565 $58,504 $92,069 Follow-up Number wrvu Financial value $550 $1360 $1910 All consultations Number wrvu Financial value $34,115 $59,864 $93,979 NOTE. Values have been rounded. The Current Procedural Terminology (CPT) codes used included initial inpatient consultation codes 99252, 99253, 99254, and 99255; follow-up inpatient consultation codes and 99233; initial outpatient consultation codes 99242, 99243, 99244, and 99245; and follow-up outpatient consultation codes 99212, 99213, and wrvu, physician work component of the relative value unit. other 31% (2180/6982) were outpatient, of which 92% (2007/ 2180) were follow-up consultations. Of the formal consultations, 84% (5827/6982) were thought to be complex, including 77% (1674/2180) of the outpatient consultations and 87% (4153/4802) of the inpatient consultations. Overall, a greater proportion of formal consultations were deemed complex (84%), compared with 78% of curbside consultations (P!.01). Of the 14,601 potential wrvus generated, curbside consultations accounted for 2480, or 17%. Table 2. Year [reference] Studies of Curbside Consultations Specialty consulted Time period, months DISCUSSION This study demonstrates that informal or curbside consultations represent a significant amount of work, are complex in nature, and have a high relative value. Curbside consultations also represent a significant amount of potential lost revenue for the infectious diseases specialist. We have previously shown that curbside consultations are common [18]. Although they affect many subspecialties, these informal consultations appear to disproportionately affect infectious diseases specialists (Table 2) [3 7, 17 19, 21, 25]. Previous studies may have underestimated the true number of curbside consultations, because of a restricted case definition of curbside consultation [8], exclusion of nonphysician health care providers [3, 6, 25], short study duration [19], restricted practice specialty [3], retrospective design [24, 25] and non time dependent data collection [17]. In addition, most of these studies were performed in metropolitan areas. The rural nature of our catchment area, with few infectious diseases specialists, may have contributed to the increased volume of curbside consultations documented in our studies [1, 26]. Several of these studies have shown that the number of curbside consultations can approach and exceed the number of formal consultations, with the ratio of curbside consultations to formal consultations ranging from 0.5 to 2.4 [6, 18, 19, 24]. Studies of mixed subspecialty groups have commented that infectious disease specialists performed significantly more curbside consultations than formal consultations [3]. We found that curbside consultations are generally complex, with a large majority given CPT codes of level 4 or 5 for inpatient consultations or level 2 or 3 for outpatient consultations. Although the percentage of curbside consultations con- Total no. of curbside consultations No. of curbside consultations per month 1984 [6] ID [19] ID [20] Gyn oncology [21] ID [22] Gastrointestinal [3] Multispecialty [23] Multispecialty [24] Pediatric ID [11] ID [18] ID [7] ID NOTE. Gyn, gynecologic; ID, infectious diseases. Value and Worth of Curbside Consultation CID 2010:51 (15 September) 653

4 sidered complex was quite high, it was slightly less than that of formal consultations. The study by Muntz [20] similarly showed a high degree of complexity of the curbside consultations received by their gynecologic oncology practice, with 74% of the informal consultations categorized as moderate (49%), very complex (22%), or ultracomplex (3%). Each curbside consultation was given the CMS assigned RVU. We elected to use only the physician work component of the RVU (ie, wrvu), thus excluding the practice expense and malpractice cost components of the RVU. We did not include the practice part of the RVU because the patients were not physically in the office. Since physicians may put themselves at legal risk by performing curbside consultations [17], it could be argued that the malpractice part of the RVU should have been included. Curbside consultations during the single year represented 1$93,000 in potential billing. These estimates were based on a 2005 Medicare conversion factor and therefore are most likely conservative estimates, compared with potential private insurer reimbursement. The only other cost estimate of informal consultations was presented in abstract form by Babinchak et al [5]. They estimated that the curbside consultations could have generated $200,000 in revenue if done formally and would have supported 1.1 full-time physician equivalents. An evaluation of the potential revenue lost to curbside consultations by a gastroenterology group suggested that a 0.2% full-time physician equivalent could have been supported [22]. Informal consultations have been referred to as the invisible part of patient care management [4, 20, 26]. They are not recognized by health care organizations and therefore are not credited to the specialist s work effort [20]. The Infectious Diseases Society of America did not mention curbside consultations in their review of manpower needs in 1996 [27, 28]. A conference about managed care in infectious diseases devoted little time to this topic, while noting that curbside consultations may be cost-effective in a capitated system and were expected without question or compensation [29, p. 345]. In a review of health care reform and the infectious diseases specialist, curbside consultations were not mentioned [30]. In addition, recent proposals by the CMS to eliminate consultation codes will further the financial devaluation of the infectious diseases specialist and will erode compensation [31]. The belief that curbside consultations should be compensated is not a new suggestion [25]. Recently, Wegener et al [12] have shown that compensating of pediatric specialists has the potential to save significant amounts of money, to be cost effective, and to improve quality of care. They offered pediatric specialists a stipend of $40 per telephone curbside consultation during an 8-month pilot project. A total of 306 curbside consultations were fielded, which led to the avoidance of 98 specialty visits, 35 hospital transfers, and 14 hospital admissions and an estimated savings of $477,274 [12]. There are several limitations to this study. The assignment of the CPT code was based on information provided indirectly to the authors and was based on the past billing experience of the authors. Both of these issues may have biased the coding assignment. The study was done at a single institution servicing a large rural catchment area with relatively few infectious diseases specialists and may not be applicable to other institutions. Hospital administrators, managed care groups, insurance companies, and academic societies need to recognize that curbside consultations represent a large volume of work, are complex in nature, and represent potentially large sources of lost revenue for infectious diseases specialists. 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